Families First Pediatric Counseling Services
Anxiety Group Therapy

This is to certify that I give permission to Families First Counseling Services for my child's participation in therapy.

I. Confidentiality
a. The personal information you share with your therapist is confidential in accordance with Utah Privileged Communication laws, professional ethical codes, and federal privacy regulations.
b. All services provided are kept confidential and will not be released to any third-party without written consent, except for billing and insurance purposes, or when required by law.
c. At times, your therapist may consult as needed with colleagues about the best way to provide you with the assistance the client might need. During these types of consultations, your therapist will discuss the case without disclosing personal identifying information (PII).
d. Please note your counselor has an ethical and legal obligation to break confidentiality under the following circumstances:
i. If there is a reason to believe there is an occurrence of child, elder or dependent adult abuse or neglect.
ii. If there is reason to believe that your child or a member of your family has serious intent to harm themselves, someone else, or property by a violent act they may commit.
iii. If you introduce a family member’s emotional condition into a legal proceeding, or your counselor is subpoenaed to give testimony.
iv. If you disclose that you knowingly develop, duplicate, print, download, stream, or access through any electronic or digital media or exchanges, a film, photograph, video in which a child is engaged in an act of obscene sexual conduct.
v. If there is a court order for release of your records.
e. Parents are entitled to information concerning their child’s current physical and mental condition, diagnosis, treatment needs, services provided, and services needed. When children are seen alone the content of the therapy sessions is kept confidential, between therapist and child, unless the child consents to sharing of such information and/or if the therapist believes the child is at imminent risk of any of the above mentioned reasons. In these instances, parents will be notified of the therapist’s concern. Any other communication will require the child’s permission. Before giving parents any information, the therapist will attempt to discuss the matter with the child and do his/her best to handle any objections the child may have.
II. Training and Supervision
a. Families First Counseling Services will occasionally have interns and paraprofessionals. All interns are under the direct supervision of licensed mental health professionals.
b. In order to ensure that counselors receive the best possible training, and that clients are well served, some sessions will be observed by our LCSWs. There will be advance notice of this, and it will be with your full and complete awareness.
c. The intern who is assigned to you is on a time-limited, contractual basis with Families First Counseling Services Therefore, it is possible that the intern may leave Families First Counseling Services prior to the end of your therapy. If this does occur Families First Counseling Services will do everything possible to ensure a smooth transfer to another counselor.
III. Counselor Availability and After Hours Emergencies
a. Counselors check for voice mail messages during normal business hours. Messages left outside of normal hours of operation will be answered on the next business day. If you have an emergency that needs immediate attention you may contact UNI Crisis Line at (801)587-300 or go to your nearest emergency room and ask to speak to a crisis worker.
IV. Child Care Release
a. Families First Counseling Services does not provide childcare and is not responsible for children and adolescents left unsupervised. If you must leave your child in the waiting room during a session, please be advised that children under 10 must have appropriate supervision. Children over the age of 10 will be allowed to wait in the waiting room at the discretion of our staff.
V. Client Rights and Responsibilities
a. You have the right to end your child’s therapy at any time, for whatever reason, without any obligation except for fees already incurred.
b. You have the right to question any aspect of your child’s treatment with your counselor and to expect that we will work with you to meet your needs for adjunctive or alternative treatment.
c. If your child sees a counselor individually, you have the right to expect that their counselor, as requested, will communicate with you about your child’s therapy. However, as the establishment of trust between your child and their counselor is important for a successful therapeutic outcome, we ask you to keep in mind your child’s need for privacy.
d. I realize that if my child is seen in therapy, both parents will be asked to participate in the treatment. This may involve family treatment, parent meetings between you and your child’s therapist, or individual therapy for each parent. Your therapist may share information regarding issues that arise in the course of the therapy with either parent.
e. You have the right to expect that your counselor will maintain professional and ethical boundaries by not entering into other personal, financial, or professional relationships with you, which would greatly compromise the therapeutic relationship.
f. Families First Counseling Services does not provide psychological testing, acting as a witness in court cases, or report writing of any kind (except for providing evidence of attendance, upon request). I agree that I will not request any of these services from Families First Counseling Services.
g. Therapy involves a partnership between therapist and client. Your child’s therapist will contribute knowledge, skills, and a willingness to do his/her best. The determination of success, however, is largely dependent upon your commitment to your child’s personal growth and care. Your signature below indicates that you have read and understand this information and have received a copy of this consent form and give permission to Families First Counseling Services to provide counseling services and that this contract is binding for all future sessions you may have with this agency.
VI. Telehealth
a. I understand that a telehealth appointment will not be the same as an in office visit due to the fact that I will not be in the same room as my mental healthcare provider. I recognize that there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties.
b. I understand that if others are present during the session, other than my mental health care provider, they will maintain confidentiality of the information obtained.
VII. Text and Email Communication
a. Text messaging and email communication may be used between client and provider if both parties agree on this communication method.
b. I understand that there are limitations to email communication and it may not be a fully secure form of communication due to unauthorized access, user error, technical difficulties, or other factors.  
c. I understand that there are limitations to the process of text messaging, however, upon your request, your provider may agree to do so. I recognize there are potential risks to this form of communication, including, but not limited to, delayed send/receipt time, unauthorized access, and text and data rates.  
d. I understand that, in the best interest of my treatment, my provider may limit all email and text message communication to administrative matters such as scheduling.  
e. I understand that, if my provider believes that it is in the best interest of my treatment to discontinue texting or emailing entirely, they will let me know.  
f. I understand that email and texting are improper means for communicating with my provider if I or my child is in a crisis. If you are experiencing a crisis please call your provider directly. If they do not answer immediately, please call the UNI Crisis Line at 801-587-3000, call 911, or go to your nearest emergency room and ask for the crisis worker on-call. 
g. By completing this form, I indicate that I understand and am willing to accept the risks involved, as well as the limitations identified above and consent to email and text message communication. 
VII. No Show/Late Cancellation Policy
For Group Therapy Self Pay payment for the class is non-refundable.
If you choose to have Families Fist Counseling Services bill your insurance for Group Therapy, a $30 late fee will be added for missed sessions.
24-hour notice is required to avoid the $30 late fee.